powerful agents we possess without which the percentage of cured cases, dermatologically considered, would be far less than it is at present.

Also that there is a certain percentage

of dermatological affections, chronic in nature, incurable by any other therapeutic means except by the proper administration of the ray.

604 Washington Arcade.

The following notes are intended simply as a preliminary report, and are presented largely to elicit the discussion as to the work which has been done by other members of our society.

The obstetrical Roentgen Atlas published by Lepold and Leisewitz in 1909, brought together in a very beautiful way, the applications of the ray to the field of obstetrics. Schoenberg, in his well-known treatise, has given the results of several of his investigations upon the feasibility of showing the living fetus.

The introduction of the new type of intensifying screen would seem to afford us new possibilities in the demonstration of the fetus in utero. Formerly, the exposures were of such length that the average operator hesitated to expose developing tissue to the long and intense radiation necessary for obtaining diagnostic plates. With the shortened exposure by the use of a screen, it would seem that this former fear can now be dispelled. The cases which the writer investigated went on to a normal delivery, with no apparent injury to the child. The cases which the writer investigated were undertaken simply with the idea of trying to find if the fetus could be shown in short exposures by the screen. The patient lay upon her side,

*Read at the forty-sixth annual meeting of the Michigan State Medical Society, Detroit, September 27, 28, 1911.

with the screen in place underneath and the large cone of the diaphragm was brought against the opposite side. The difficulty in making lantern slides of such plates as were obtained precludes the demonstration of these plates by the lantern. The transparencies, however, which were made, and which we will now pass around, show that the head can be shown with the upper and lower jaw, and the wall of the orbit as well as the fontanelles, the thoracic cage and the long bones. This enables us to orient, in a rough way, the condition of the fetus, telling whether the presentation will be occipital or breach. The differential diagnosis between a single or twin pregnancy can also be made. It has not been the good fortune of the writer to have a case for the diagnosis of tubal pregnancy, but there have been a number of cases upon record. †

The conclusions which the writer would present from his small number of cases would be; first, that the short exposures made possible by this screen can be made in pregnancy without hastening the termination of pregnancy and without apparent injury to the living fetus; second, the Roentgen ray can be used in the later

+Since the above article was written the author has been able, in a case of doubtful diagnosis of pregnancy, to show the presence of a fully formed fetus when the clinical diagnosis was fibroid of the uterus.

The object of this paper is to call your attention to the interdependence of surgery and medicine, with a plea for more recognition of the attending physician in the after-care of his operated patients.

In all fields of medical practice, the last 25 years shows tremendous progress; in preventive medicine, in diagnosis, in treatment. Never before have we had so many resources at our command for the relief of suffering and the cure of disease. The great essential is diagnosis, followed by the intelligent application of the indicated remedy.

The rapid development of medical specialties has blinded the profession to the fact that the human body cannot be readily subdivided into its individual parts, medically, but must be treated as a composite whole, with special attention to any diseased part. There is no organ or tissue of the body independent of some other and but a limited number of disease manifestations are entirely local. Granting the truth of the foregoing statement, it axiomatically follows that the needs of the public can be best served by well trained general practitioners, broad minded enough to grasp the symptom complex and call to their aid the skilled assistance of the expert specialist in any needed line.

At present, there is too little in common between the general practitioner and the specialist. Probably the majority of

*Read at the forty-sixth annual meeting of the Michigan State Medical Society, Detroit, September 27, 28, 1911

the work of the specialist comes to him direct, without reference by the family physician, who, recognizing the condition without acknowledging the cause, often hesitates to add to the prestige of the specialist by calling him in consultation when he really needs his assistance.

The real reason for the present popularity of the specialist is the good work which he does, and the real reason for the decadence of the family physician is his poor work, through his lack of attention to detail in diagnosis and his failure to recognize and properly treat the many minor local conditions upon which specialism thrives. For example, the average physician is content to write a prescription for "gleet" or "piles," without examination, just for a dollar, while the specialist makes an elaborate examination with impressive technique, knows what is the matter, cures the condition and collects accordingly. Yet, with some training along special lines, a few inexpensive instruments of precision, and an educated sense of touch, any general practitioner should be able to diagnose and successfully treat these, and many similar local ailments now so largely in the hands of specialists. The ordinary minor lesions of the eye, ear, nose and throat, the ordinary non-surgical diseases of the genito-urinary tract in male or female, and diseases of the rectum, should be recognized and treated by modern methods by every family physician; then your offices will again be filled with the patients who now travel from office to

office for treatment of their various ailments.

Every specialist practices more general medicine than specialty. Try as he may, he can isolate his special organ from its environment but occasionally. He treats local conditions locally, and, local conditions of systemic origin systemically. The general practitioner, from his broader viewpoint, is better able to correlate diverse symptoms than any number of star specialists, and better able to determine what, if any, special treatment is needed. He learns his patient's constitutional idiosyncrasies and his degree of resistance to disease, hence, can best aid the "vis medicatrix naturae," our most efficient aid toward recovery of strength and function. Excepting degenerative and malignant disease, severe infections and fatal traumatism, all disease conditions tend toward recovery. We but assist nature, we do not cure. This is never more true than in surgical

cases.

We set the fracture by restoring continuity, perhaps badly, but the rebuilding of tissue and regaining of function are Nature's, and very slight is the aid we can render in this process. In operative surgery this is also true, and if the patient lives through the anesthetic and escapes infection and hemorrhage from faulty surgical technique, we are dealing with a convalescent patient. Nature conducts the repair, fights off invading bacteria, and seals up the wounded vessels and tissues, while we only aid her by not interfering.

Why, then, should the operator feel that because he held the knife and needle, he must attend the patient during a convalescence, which, if he has done his work properly, tends toward an uninterrupted recovery? Can he do more for the interests of the patient by usurping the place of the physician who called him as consultant, and, if so, what? Take, for example, an uncomplicated abdominal

section. Pathological tissues have been removed, bleeding vessels ligated, the wound closed and the patient placed in bed. If the operator has worked quickly and carefully, there is little shock and no hemorrhage or infection. What more is there to be done? Simply to watch the case for possible complications, in the event of which, the surgeon is usually as powerless as the physician. Without complications the patient is a convalescent, needing but a regulation of diet. and elimination and advice as to when to sit up and go home. Wherein, then, does the surgeon fail of his duty, by imparting to the attending physician any special after care whims he may have and watching with the physician, in the role. of consultant, until danger of complications is over?

If the operator be a good surgeon, complications develop but rarely in uncomplicated cases. Angus McLean has recently reported 2036 operated cases with a surgical mortality of 1.2% (peritonitis 5, ileus 6, thrombosis and embolism 6, tetanus I, hyperthyroidism 2, acute pancreatitis 1.) A glance at the above causes of death shows that none of these occasional complications could have been averted by the most watchful after-care. The point under discussion is, of course, whether the personal and direct attendance of the operator prevents fatalities which would occur with the family physician in attendance and the operator as consultant. We submit, as our premise, that any well trained practitioner is competent to conduct the after-care of any operated case. It is possible to do harm by careless dressing, in delicate eye operations, in abdominal and pelvic operations with drainage, and in prostatectomies. In such cases, the physician will recognize the trained hand of the surgeon and want him to do the special dressings, in his

capacity of consultant. In all other cases, the attendance of the surgeon after operation is unnecessary except in an advisory capacity. He should share the responsibility without usurping, by word, act, or manner, all of it. He should give his suggestions to the physician or to the nurse, for the physician. It rarely, if ever, occurs that the advice of his consultant is not followed by a physician, both in letter and spirit. This is fundamental in the practice of medicine and as true in surgery as in any other field of practice. Per contra, the present day metamorphosis from consultant surgeon to attending physician is unique in medicine. In no other field does the consultant feel his responsibility keenly enough to bite the hand that feeds him.

Does the Roentgenologist treat your fracture case, or the consultant who makes a difficult obstetrical delivery for you insist upon conducting the after-care? Does the expert in internal medicine who makes an autogenous vaccine for your pneumonia patient take the case? Does the pediatrician take your case of meningitis because he makes a spinal puncture?

The true relation of surgery to medicine is that of a mechanical aid to general treatment. It occupies but a part of the field and a part inseparable from the rest of the field. Its relation to general practice is identical with all the other specialties, i. e., each is a branch of one great whole. In relation to the general practitioner, every specialist is a consultant for all referred work. Every well-known specialist has many patients coming to him direct, drawn by his famed skill. He sometimes treats these cases as his own, without obligation to any practitioner, or may refer them back to the family physician for general treatment. On all referred work the specialist confers with the physician and is largely guided by

his wishes in his further connection with the case.

The surgeon has four avenues by which business comes to him:

1. Cases coming direct.

2. Out of town cases, referred for operation in the city hospital.

3. Operations out of town. 4. Referred cases in town. With the first two classes the surgeon, in accordance with the present custom, has no professional obligation. He may or may not call in the family physician in city cases coming direct, but he must care for patients coming from a distance, until they are able to go home. In class 3, he has no option; he consults or operates, leaves the after-care to the local physician and does not see the case again unless complications ensue.

In class 4, he should continue as a consultant through the case. He was called in for that purpose and his expert advice is welcomed by the attending physician. It is neither necessary or desirable that he take entire charge of the after-care, to the exclusion of the attending physician. In point of fact, much after-care in hospital practice is left to assistants or internes, which should be left to the family physician. Both physician and patient would be benefited thereby, for the physician brings personal interest and, usually, wide experience, in contrast with the routine service of assistant or interne. Exclusion of the physician from after-care responsibility makes his visits purely social. Few patients want to pay for social calls, and few physicians are willing to make them.

As a result of the exclusion of the attending physician from a share in the responsibilities and the emoluments of surgery, every physician is now doing all the surgery he dares, and many of those too timid are asking a division of the fee